1124100755 NPI number — IMTIAZ A CHOUDHARY MD

Table of content: IMTIAZ A CHOUDHARY MD (NPI 1124100755)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124100755 NPI number — IMTIAZ A CHOUDHARY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHOUDHARY
Provider First Name:
IMTIAZ
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124100755
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
224 D CORNWALL STREET NW
Provider Second Line Business Mailing Address:
STE 403
Provider Business Mailing Address City Name:
LEESBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20176-2704
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-737-6010
Provider Business Mailing Address Fax Number:
703-443-8643

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6226-A OLD FRANCONIA ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22310-3404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-313-5060
Provider Business Practice Location Address Fax Number:
703-313-9446
Provider Enumeration Date:
10/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X , with the licence number:  0101054520 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 30016167640001 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 401849400 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1124100755 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 017113900 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010020751 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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